Patient Registration | Oak Ridges Medical a

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OAK RIDGES MEDICAL

URGENT CARE CENTRE

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Patient Intake Form

Please fill out the following form to help us understand your physical condition.

Patient Information

First Name

Email Address

Health Card #

Address

Last Name

Gender/Sex

Health Card Version Code

City

Date of Birth

Other (Gender Here)

Phone

Province

Postal Code

Emergency Contact

Name

Name

Relationship

Relationship

Phone

Phone

(symptoms, diagnosis, duration, onset)

Health History & Concern

Health Concern

Allergies

When Did It Start?

Are you currently suffering from a medical condition, illness, or injury? *

No

Yes

Have you been hospitalized in the last 12 months? *

No

Yes

If you answered yes to any question, please elaborate

Medications

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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